10/1/2016. Prevalence and projections. Primary prevention of Alzheimer s disease and related disorders in a community health system

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1 Primary prevention of Alzheimer s disease and related disorders in a community health system 2016 ISAPN MIDWEST CONFERENCE, October 7, 2015 Lisle, Ill. Anne Marie Fosnacht, MPH NorthShore University HealthSystem Prevalence and projections 1

2 Beneath the hood: Successful aging Cost and projections Beneath the hood: co-morbid hospitalizations 2

Genes: An important distinction Mutations in Presenilin 1 & 2 (others)

worldwide Portrayed in Still Alice Deterministic/certainty 3 Common

variation carries a different risk for developing Alzheimer s disease

Easy as 2, 3, 4 5 2 1 2/2 Half as likely 10 3/3 3/4 2/3 Half as likely 18

3 Genes: An important distinction Mutations in Presenilin 1 & 2 (others) Early onset: age 45 to 65 Runs in families Very rare: 20 families worldwide Portrayed in Still Alice Deterministic/certainty 3 Common variations (6 possible genotypes) in gene Apolipoprotein-e APOE Each variation carries a different risk for developing Alzheimer s disease 100% of people have an APOE genotype RISK not CERTAINTY APOE Genotypes: Easy as 2, 3, /2 Half as likely 10 3/3 3/4 2/3 Half as likely /3 4/4 2/4 2/2 2/4 3/3 3/4 4/4 3 x more likely Average risk 3 x more likely 15 x more likely 3

Prevalence of Cerebral Amyloid Pathology in Persons without

Disparity 2010 Sufficient evidence Diabetes Depression Smoking

education Exercise/physical activity Social engagement Medications

4 Prevalence of Cerebral Amyloid Pathology in Persons without Dementia: A Meta-Analysis Jansen, W.J. et al JAMA(2015) 313; 19: Disparity 2010 Sufficient evidence Diabetes Depression Smoking Genetic factors (APOE) Insufficient evidence Years of formal education Exercise/physical activity Social engagement Medications (NSAIDS, Statins, antihypertensives, estrogen) Alcohol abuse Dietary factors 4

5 5

Diabetes--midlife hypertension--midlife obesity inactivity depression smoking--low

6 Potential for Primary Prevention of Alzheimer s Disease: An Analysis of Population-based Data Norton, S. et al (2014) Lancet Neurol 13: Diabetes--midlife hypertension--midlife obesity inactivity depression smoking--low education Exercise Training Increases Size of Hippocampus and Improves Memory Erickson, K.I., et al (2011) PNAS. 108(7)

7 Do behaviors really matter when you carry the APOE 4 allele? In cross-sectional analyses, moderate seafood consumption was correlated with lesser burden of brain Alzheimer disease neuropathology in APOE ε4 carriers Morris et al (2016) JAMA 315(5): For those with 12 years of schooling or less, APOEɛ4 has a strong negative association with cognition. This negative effect dissipates for those with 16 or more years of schooling. Cook, C., et al (2015) Social Science and Medicine. 127; APOE ε4 carriers particularly benefit from increasing physical activity with regard to their risk for Alzheimer s disease. Luck T., et al (2014) Psychol Med 44(6):

8 Research Our Quality Journey Structure Process Outcomes 10 neurological disorders and Epilepsy Migraine Sleep MS ALS Movement disorders (Parkinsnon s) Memory disorders (Alzheimer s) Brain Tumors RLS (Restless leg syndrome) Stoke Brain Health Neurology Practice Based Research Network (NPBRN) Dartmouth (Massachusetts) Medical University of South Carolina Ochsner Health System (Louisiana) St. Luke s Health System (Missouri) University of Arkansas University of Cincinnati University of Florida University of Nebraska University of Pennsylvania Wake Forest (North Carolina) NorthShore University HealthSystem 8

The DodoNA Project: DNA predictions to improve neurological health Dodona was an oracle of

predict the future and to guide actions to improve fate.

9 The DodoNA Project: DNA predictions to improve neurological health Dodona was an oracle of ancient Greece, where priestesses interpreted the rustling leaves of a sacred oak tree to predict the future and to guide actions to improve fate. Just as at DodoNA, we can interpret subtle variations in DNA, the tree of life, to predict outcomes and to improve health. 11 longitudinal cohorts 1,000 subjects per cohort 1,000 fields of data per office visit 10 years median follow up 1,000 DNAs per cohort 1 million SNPs per DNA CLINOMICS integrating genomic and clinical practice data 9

10 10

11 A Patient Story Douglas 41 years old Heard about the Center for Brain Health at a Community Fair Concerned about Family History Maternal grandmother Paternal grandmother 11

12 Doug s 1 st visit with Brain Health Physician Revealed: Obese by BMI Hypertension Sedentary poor diet (scored 3 on Med diet questionnaire) Willing to change (high score on Readiness Assessment) Anxiety (measured by GAD-7) Low caffeine intake Orders APOE genetic test Vitamin D labs Lipid panel Dietitian referral Social work referral (passed on physical/exercise therapy referral for now Brain Health DodoNA (consented to give blood sample for DNA) Lab Results APOE 4/4 (highest risk/most to gain) Severely deficient in Vitamin D Hypercholesterolemia 12

13 Patient s next steps: Referred to Dietitian Referred to Social Worker Prescribed Vit D and folbic 1-month follow-up with PA Doug was very moved by the appointments with our physician & dietitian. He stated he has completely changed his diet. While he sort of expected he would have a 4/4 genotype based on his family history, seeing it on paper like that has moved him to mitigate all of the risk factors he has control over. Reports exercising 5-days a week Weight loss measured Taking Vitamin D and prescription Folbic (folic acid, B6, B12) Doug: summary Risk factors identified Immediate Action Future Action APOE 4/4 Midlife obesity Dietitian referral 6-month & yearly follow-up Midlife hypercholesterolemia Dietitian referral 6-month & yearly follow-up Vitamin D deficiency PrescribedVit D 6-month & yearly follow-up Standard American Diet Dietitian referral 6-month & yearly follow-up Sedentary Exercise on own volition 6-month & yearly follow-up 13

14 In summary Identification of at-risk individuals in a population, intervention and surveillance Primary prevention Utilizing the EMR to identify patients, learn about our cohort, practice-based research, genomic research All possible systematically in a hospital system To reduce the burden of disease in the communities we serve 14

NCI Data Brief. ISSUE 6 December 2012

NCI Data Brief. ISSUE 6 December 2012 NCI Data Brief ISSUE 6 December 2012 What does NCI tell us about adults with intellectual and developmental disabilities who are taking prescribed medications for anxiety, behavior challenges, mood disorders